Meaningful Use and Clinical Analytics

Lynn R. Witherspoon, M.D. System Vice President

Chief Medical Information Officer Ochsner Health System

New Orleans, LA

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Ochsner Health System HIT • Uniquely identified our patients and our providers • Provider group practicing with an Electronic Health

Record • Hospitals with standardized HIS, Departmental

platforms • Community physicians have access to Ochsner’s

information systems through a web-based Community Provider Portal

• Moving to a more fully integrated practice support and electronic record platform (Epic)

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The Electronic Health Record • A repository of historical and observational data

collected iteratively over time – structured and text • A record of thoughts, impressions, opinions • A place to develop, manage, and document the

execution of a plan of care • Support for the care processes –e.g. Documentation,

Lists, Orders, Medication Management, Results and communication both internally and externally

• Decision support – Health Maintenance Reminders, Order Sets

• Gateway to community-based health information • Practice support – Demographics, Access, Billing

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Problems with the Medical Record

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Problems with the Medical Record • The “story”, structure from free-text (might NLP help?) • Electronic templates but how good is the structured data? • “Cut and Paste” – actual, virtual • Interoperability and Health Information Exchange

immature, evolving • Process variation within and across providers • Decision support often not supportive – Clinical

Outcomes, economic, workload, efficiency • Failure to provide cognitive support • Who is it all for anyway? – Legal, Billing; ICD-10

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Current Provider Engagement with OCW

Provider

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BAEZ, Raymond 382 99% 30% 1% Yes 19% 346% No ALL

BENNING, Gurpal S. 363 100% 84% 207% Yes 47% 218% No ALL

BRADFORD, Roger M. 164 100% 69% 1% Yes 1% 142% No MSG/RRS

DUNN, Michael A. 370 100% 100% 14% Yes 1% 207% No MSG/RRS

FITZPATRICK, James B. 298 100% 92% Yes 2% 413% Yes ALL

GAROFALO-ABEL, GANESA 288 100% 85% 97% Yes 10% 249% No MSG/RRS

HUDSPETH, Ted J. 302 100% 86% 1% Yes 0% 621% Yes MSG/RRS

JENS, Daniel K. 250 100% 93% 36% Yes 3% 166% Yes ALL

MAREK, Richard G., Jr. 199 100% 98% 82% Yes 47% 326% Yes ALL

NEWCOMB, James H., JR. 158 99% 93% 111% Yes 28% 550% No MSG/RRS

NIETO, Sandra S. (PT) 336 100% 98% 85% Yes 9% 275% No ALL

PALMISANO, Vernon K. 246 6% 94% 218% Yes 12% 335% Yes ALL

PLAISANCE, Kevin C. 294 100% 87% Yes 1% 246% Yes ALL

REISER-PARMENTER, Jeryl L., D.O. 282 100% 88% 1% Yes 55% 117% No ALL

RIDDELL, Timothy L. 281 98% 90% Yes 9% 469% Yes ALL

ROBINSON, Herbert G., III 356 100% 39% 0% Yes 1% 125% No MSG/RRS

SCHIRO, Richelle D. (PT) 169 100% 95% 196% Yes 20% 169% Yes ALL

SEARLE, C. Roger (PT) 169 4% 60% 2% Yes 0% 296% Yes MSG/RRS

SPARKS, Gerald J. 415 100% 70% 110% Yes 2% 202% No MSG/RRS

TAYLOR, Robert W. 380 99% 100% 79% Yes 6% 373% No ALL

90% + 90% + 50% + Yes 50% + 100% + Yes ALL

50 - 89% 80 - 89% 20 - 49% 20 - 49% 50 - 99% Some

<50% <80% <20% No <20% <50% No No

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Can Electronic Health Records help us take better care of Patients?

Enter “Meaningful Use”

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The American Recovery and Reinvestment

Act of 2009 – Health Information Technology for Economic and Clinical Health

• $19 billion for Health Information Technology – Ochsner’s share is about $50 million

• Incentive payments to Eligible Providers and Hospitals to adopt and successfully demonstrate “meaningful use” of certified electronic health record (EHR) technology.

• Penalties for not adopting EHR

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Objectives of “Meaningful Use”

– Improve quality, safety, efficiency, and reduce health disparities

– Engage patients and families – Improve care coordination – Ensure adequate privacy and security

protections for personal health information – Improve population and public health

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Electronic Health Record Certification

• Specifies standards, implementation specifications, and certification criteria to enhance the interoperability, functionality, utility, and security of health information technology

• Specifies required capabilities needed to support achievement of Stage 1 Meaningful Use

• Ensures that implementation of a certified EHR provides providers with the minimum tools necessary to successfully achieve Stage 1 Meaningful Use

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Electronic Health Record Vendor Dependencies

• Implications of Certification • Interpretation of Meaningful Use requirements • Functionality designed to enable Meaningful Use (but not

necessarily to support optimized or desired provider workflow)

• Data Capture and Data Management • Data Visualization • Data Infrastructure • Reporting Infrastructure

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Meaningful Use

• Patient centric but provider measured • Incentivizes the behavior (defined as

“Meaningful Use” “Objectives”) of individual “Eligible Providers”

• No group reporting but clear group advantage (“seen by you” rather than “done by you”)

• Measures and reports process metrics • Implication is that improved care, care outcomes

will follow

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Meaningful Use • Eligible Provider

– >10% “Ambulatory” site of service on Medicare charges Excludes In-patient and ED but does include Hospital

Outpatient

• All or Nothing - All EPs must meet all of the Meaningful Use requirements to receive incentive/avoid penalty – 15 Core Objectives (one of which requires reporting quality

metrics) – 5/10 Menu Objectives – 6 Quality Metrics – 3 Core, 3 Menu

• One Size Fits All – There is only one set of Meaningful Use requirements to which all are subject

• Rules are complex

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Core P101 CPOE 30%with at least one

medication order P102 Drug – Drug and Drug – Allergy check P104 Maintain Problem List 80% P105 ePrescribe 40% eligible P106 Maintain Medication List 80% P107 Maintain Medication Allergy List 80% P108 Patient race, ethnicity 50% P109 Vital signs (Ht, Wt, BP) 50% P110 Record smoking status 50% P114 Quality measures P116 Clinical decision support rule P117 Give patient electronic copy of record

upon request 50% P120 Give patient After Visit Summary 50% P122 Exchange clinical information P128 Privacy and Security – HIPAA risk

analysis

Menu (select 5) P103 Drug – Formulary checking P112 Lab Results as structured data 40% P113 Generate list of patients by condition

(at least one report) P115 Patient reminders 20% >65 years or

<5 years P119 Timely electronic access to health

information 10% P121 Patient specific education 10% P123 Medication Reconciliation 50% at

care transitions P124 Summary of care 50% at care

transitions and referrals P125 Submit Immunization data to state P126 Syndromic Surveillance (One of the 5 must be from the last 2)

Eligible Provider Objectives

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Eligible Provider Quality Measures

Core NQF 0013 Hypertension Blood Pressure

Management NQF 0028 Preventative Care and Screening

Measure Pair: a) Tobacco Use Assessment, b) Tobacco Cessation Intervention

NQF 0421/PQRI 128 Adult Weight Screening and Follow-up

Alternate Core NQF 0041/PQRI 110 Influenza Immunization

for Patients >50 Years Old NQF 0024 Weight Assessment and

Counseling for Children and Adolescents NQF 0038 Childhood Immunization Status

Additional Quality Measures (select 3) from a menu of 38 Quality Measures

Most are derived from administrative data

or laboratory results Several are derived from textual

documentation, for example: Asthma Assessment Weight Assessment Diabetic Foot Exam Diabetic Retinopathy

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Enabled in the Provider’s EHR • Drug-Drug, Drug-Allergy Checking • Clinical decision support rule • Exchange Clinical Information Electronically (HIE) • Privacy-Security – HIPAA risk analysis

• Drug-Formulary Checking • Lab Results as structured data • Patient Reminders • Submit immunization data to state • Syndromic surveillance

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Ideal Workflow

Check In/ Rooming •Demographics •Vital Signs •Smoking History

Visit with Provider •Visit Diagnosis •Problem List •Review History •Plan – Orders, Medications •Progress Note

Check Out/Farewell •Schedule Appointments •After Visit Summary

Access Patient Portal •Educational Material •Reminders •Access to Health Info

In Box • Results Management • Messages

• From Patients • From Staff

• Close & sign charts

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Data Capture • Documentation that an activity has occurred

• Administrative data • Laboratory result • Indication within a workflow (e.g. “Mark as Reviewed”, order

entered, prescription written) • Text

• Structured data • Notewriter • Links • Lists (pick lists, drop-down menus) • Text – Natural Language Processing

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Analytics with Meaningful Use

EMR - Tools - Documentation - Process

Records in Transactional

Database

MU Reporting Repository

MU Reports

Results

Provider Feedback

MU Report Logic Extract

Data Transformation

Activities

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What is required of the Meaningful Use data management/reporting system? • We are given the desired outcomes • We are told who is accountable for the meaningful use of

an electronic health record • We are given the objectives that are expected to

produce the desired outcomes • Most have thresholds, some are reported by attestation • We are given some associated quality (process) metrics • We are required to report compliance with objectives as

well as process metrics to CMS

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Assembly of the Meaningful Use Data Management System • Who are our Eligible Providers (Registration)? • What is the exact definition of each Objective? • How will we know when Objectives are met? • What is the exact definition of each Quality Measure? • How will we capture the Quality Measure data? • Validation of the transaction database extraction and

Meaningful Use reporting repository load • Design of the Reporting System

– Denominators and Numerators

• Report validation • Attestation

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Objective Report ConfigurationRequired if Reporting on Associated Objective? Setting Options Your Values Location of Setting Name of Setting Special Update Notes

General Indentify a list of the facility records that should be considered a hospital for Meaningful Use reports. For each facility, the report calculates measures based only on patients seen in a department of the hospital.

Required Facility (EAF) records Complete for NorthShore Hospital Facility number 7301

EMR System Definitions > Meaningful Use > Facility Structure Configuration for Eligible Hospitals

Facilities to include as eligible hospitals (I LSD 91080)

General Identify a list of departments that are included in a facility you listed in the prev ious setting (Facilities to include as eligible hospitals (I LSD 91080)), but that should be excluded from Meaningful Use reporting. This configuration ensures that patients not seen in an inpatient or ED department, such as psychiatric or rehabilitation patients, are not included in reports. (Note that you should not use this setting to exclude outpatient departments, as that exclusion is already handled by the report logic.)

Optional Department (DEP) records Northshore Excluded Departments EMR System Definitions > Meaningful Use > Facility Structure Configuration for Eligible Hospitals

Departments to exclude from eligible hospitals (I LSD 91085)

General Identify the CMS Certification Number for each hospital in your organization.

Required Free text value entered in the facility record for each hospital in your organization.

Hospital CMS Certification Numbers In Chronicles, open the Facility (EAF) record for each hospital in your organization

CMS Cert Number

General Identify the way in which you will indicate that a patient is in observation following a v isit to the ED. This is used to determine the ED patients that should be considered for Meaningful Use reports.Many organizations use patient class for this purpose. With Special Updates, you can alternatively use admission status, emergency events, or hospital serv ice values. You can identify multiple values from multiple items, as appropriate. These values might be appropriate if you are not licensed for ADT, for example.

Required ( Without SU described in Special Update Notes) Values from ADT: Patient Class (I EPT 10110)( With SU described in Special Update Notes)1 - Values from ADT OBS Patient Class (I EAF 70109)2 - Values from MU Observation Hospital Admission Status (I EAF 75430)3 - Values from MU Observation ED Events (I EAF 75431) 4 - Values from MU Observation Hospital Serv ice (I EAF 75432)

Using method 1: Valued from the ADT OBS Patient Class. Personal communication from Jack Gonzales to Kent Boyer 9/26/11. From Jeanne Ory:All emergency patients are automatically assigned a hospital account with a patient class of "Emergency." If the patient then needs to be admitted, the physician would write an admit order and specify either an "OP-Observation " or "IP-Inpatient" patient class and then transfer the patient to the appropriate floor.

( Without SU described in Special Update Notes) Meaningful Use Hospital Stored Procedure (ESP_F_MU_OBJECTIVE_IP)(With SU described in Special Update Notes)Clinical Administration > Facility Structure > Facility/Serv ice Areas (EAF) > Meaningful Use - Observation Settings

( Without SU described in Special Update Notes) P_OBSERVATION_PAT_CLASSES( With SU described in Special Update Notes)Admission StatusEmergency EventsHospital Serv icePatient Class

To use values other than patient class, you must install one of the following Special Update packages: Epic 2010: E7800718Summer 2009: E7707818Spring 2008: C7602129

General Identify ADT admission codes or admission source values that indicate that a patient is a newborn admitted to the nursery. This exclusion is helpful because many objectives are not applicable to newborns.

Optional Category values from ADT Accommodation Code (I EPT 10121) and Admission Source (I EPT 10310)

Per team discussion 6/5/12 - this will not be entered.

Clinical Administration > Facility Structure > Facility/Serv ice Areas (EAF) > 1 > Meaningful Use - Exclusion Settings screen

ADT Accommodation Code fieldAdmission Source field

To use these settings, you must have one of the following Special Update packages:Epic 2010: E7805189Summer 2009: E7709729Spring 2008: Not available

H101 Identify the method that the report uses when measuring CPOE.

Required 1 - Measure CPOE based on the ordering prov ider (and verbal order mode if configured using the setting detailed on the following line)2 - Measure CPOE by checking the license of the entering prov ider

1-Measure CPOE based on the ordering prov ider (and verbal order mode if configured using the setting detailed on the following line) (mt 08/10/11) -decision signed off by Dr. Milani per Tressan

EMR System Definitions > Meaningful Use > Meaningful Use CPOE Settings

Meaningful USE CPOE criteria

Note that this Decision Tracker is a supplement to the Meaningful Use Objectives Guide and is not intended to include all of the information needed to make each decision. Review the associated objectives in the Objectives Guide and make decisions after understanding the full context of the objective and how your decision will affect the reporting results.

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NQF # Title Description CoreProvider Workflow Required System Components

1) Diagnosis Grouper 2100006655-EDG ICD-9 MU A_C69 Hypertension Diagnosis codes representing hypertension diagnoses for the “diagnosis active: hypertension” data element

2) Procedure Grouper 2100007052-EAP General MU A_C26/A_C28 CPT Ambulatory Outpatient and Nursing Facility Encounters Procedure records representing the level of service codes for the “encounter: encounter outpatient” or “encounter: encounter nursing facility” data element3) BestPractice Advisory base 8004-Base MU NQF 13 - BestPractice advisory record containing details about meeting this measure4) BestPractice Advisory criteria 8049-CL MU NQF 13. BestPractice advisory record that triggers the advisory based on the logic for this quality1) Procedure grouper 2100006544-EAP General MU N_C27 CPT Outpatient Encounters. Level of service codes representing outpatient encounters that are part of the “Encounter: encounter outpatient w/PCP & obgyn” data element2) Diagnosis grouper 2100007043-EDG General MU N_C159/N_C417 ICD-9 Outpatient and OB-GYN Encounter Diagnoses. Diagnosis codes that are part of the “Encounter: encounter outpatient w/PCP & obgyn” data element3) Diagnosis grouper 2100006672-EDG ICD-9 MU N_C417 OB/GYN Encounters. Diagnosis codes that are part of the “Encounter: encounter ob/gyn” data element4) Diagnosis grouper 2100000599-EDG General MU N_C124 ICD-9 Pregnancy. Diagnosis codes that are part of the “Diagnosis active: pregnancy” data element5) Diagnosis grouper 2100006634-EDG ICD-9 MU N_C167 Exercise Counseling. Diagnosis codes for the “Communication to patient: counseling for physical activity" data element

6) Diagnosis grouper 2100006671-EDG ICD-9 MU N_C162 Nutrition Counseling. Diagnosis codes that are part of the “Communication to patient: counseling for nutrition” data element

7) Diagnosis grouper 2100006623-EDG ICD-9 MU N_C160 BMI Percentile8) SmartText 10390- Ped Well Child Check 24 Months. 9) SmartText 10391- Ped Well Child Check 3 Years. 10) SmartText 10392- Ped Well Child Check 4 Years. 11) SmartText 10393- Ped Well Child Check 5 Years. 12) SmartText 10394- Ped Well Child Check 6-8 Years.13) SmartText 10395- Ped Well Child Check 9-11 Years. 14) SmartText 10436- Ped Well Child Check Adolescent. 15) SmartList 19964-PED MU Obesity Counseling. SmartList linked to SmartData elements documents patient was counseled16) BestPractice Advisory Criteria 8052-CL MU NQF 24. Locates patients w/missing BMI or BMI outside of range17) BestPractice Advisory Base 8007-Base NQF 24. Recommends documenting a BMI or following up with nutrition/activity counseling

NQF 0013Blood Pressure Measurement

Percentage of patient visits for patients aged 18 years or older with a diagnosis of hypertension who have been seen for at least 2 office visits, with blood pressure (BP) recorded.

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1) When a patient with hypertension is seen, a clinician ensures that hypertension is on the patient’s active problem list. 2) If not, provider adds hypertension to the patient’s problem list (and records hypertension as an encounter diagnosis, if appropriate). 3) During each encounter, nurse documents patient’s blood pressure, either in the Vitals navigator section or the Encounter Vitals documentation flowsheet.

1) Patient aged 2-17 is seen, nurse records patient’s weight and height in the Vitals navigator section or a documentation flowsheet - values used to calculate the patient’s BMI. 2) Provider enters a V-code for nutrition and physical activity counseling as an encounter diagnosis. 3) Provider can also document information in a progress note by using SmartTexts with appropriate SmartLists to document that patient has been counseled regarding nutrition and physical activity.

Alt

The percentage of patients 2‐17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of BMI percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year.

Weight Assessment and Counseling for Children and Adolescents

NQF 0024

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Special Cases • Consequent the site of service definition Radiologists,

Pathologists, Anesthesiologists, Hospitalists are “Eligible Providers”

• What constitutes “my patients”, “visit”, “seen by me” for these providers (what’s in the denominator)?

• Eligible Providers have face-to-face “visits” or only provide “in-the-dark” services or some combination of the two.

• How will these providers meet Meaningful Use requirements (what’s in the numerator)?

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Clinical Analytics in the context of Meaningful Use • In the short term Meaningful Use is about data

management and visualization • Analytics could bridge the gap between simply providing

observational information and the desired outcome (better care).

• Becomes more relevant in future Stages were behavior thresholds are significantly increased?

• Provides opportunities to understand process impact on outcomes?

• Status and trajectories predictive of outcomes? • Will this scale to support other improvement initiatives,

e.g. HEDIS, JCAHO, PQRS, Medical Home, ACO?

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Questions?